Police have launched an investigation after the deaths at the home in Marchwood

Officers carried out the inquiry into the deaths of the pensioners at the Oaklands Rest Home in Veals Close, Marchwood between September and December, 2014 after concerns raised by Hampshire County Council.

But following the investigation it was decided there was not sufficient evidence to recommend prosecution.

Hampshire Police then carried out a case review but decided not to take the case any further.

Details were revealed at an inquest into the death of one of the pensioners at the centre of the inquiry.

The three cases investigated involved a pensioner who died after choking on a sausage roll, another who was found dead at the bottom of stairs and a third who died after allegations were made against the home by her relatives.

In all three case the home was cleared of any blame.

At Winchester Coroner’s Court the detective sergeant at the time Naomi Melish told the hearing that police investigated the deaths.

She added that they brought the case before the Crown Prosecution Service and later the serious crime review, but there was not enough evidence to continue proceedings.

One of the deaths was that of Pamela Carey, 77, who had only been at the home for two days when she choked on a sausage roll and suffered a heart attack. She died three days later at Southampton General Hospital.

The inquest heard how Mrs Carey suffered from Alzheimer’s, diagnosed in 2011.

Speaking at the inquest, her husband Raymond Carey said he told staff at the home before she arrived that there was a risk of choking due to loose dentures and she needed supervision when eating.

The court heard how Mr Carey visited on August 25 to fill in a pre-assessment form with a staff member, which would be what Mrs Carey’s care management plan would be based on.

He came back to the home on September 1, and raised concerns about his wife’s need to be supervised while eating.

The pre-assessment care forms, however, showed no note of this, but the updated September form did indicate she had dentures, which were not there in April.

Giving evidence, Ashleigh Rutherford, a senior carer at the home, explained she had gone through the pre-assessment form with Mr Carey and would have noted supervised eating in the form.

The hearing heard a statement from carer Casey Barnes who said she left Mrs Carey after making her a sausage roll, and on her return Mrs Carey was unresponsive.

Ms Barnes said she had left her for two minutes, but the coroner and her employer Amish Patel disputed this and said it was more likely to be five to ten minutes.

The inquest also heard how Ms Barnes believed Mrs Carey suffered a heart attack and ambulance staff asked her to perform CPR before they arrived within 13 minutes.

Pathologist Dr Russell Delaney said the cause of death was a brain injury due to prolonged cardiac arrest caused by choking.

He said although it would be helpful had Mrs Carey been supervised when eating, it may not have prevented her death as dementia sufferers are prone to choking, but it may have sped up the process of medical attention arriving.

Coroner Simon Burge recorded a narrative verdict and did not blame staff members.

The second inquest was into the death of 83-year-old Irene Price, who suffered a brain injury after a fall on December, 2014.

The court heard she suffered dementia of a type strongly associated with falls.

She walked around independently with a crutch but had fallen “loads of times” and needed supervision on stairs, care assistant Alecia Martin said.

“She’s the type of person who, sometimes, you can’t tell her what to do. She just does what she wants,” she said.

The carer told how she took Ms Price to a ‘quiet room’ after an altercation with another resident.

Ms Martin walked around the corner to make a cup of tea and heard a loud bang, she said. Ms Price was found on her back at the foot of the stairs.

She was taken to Southampton General Hospital, where doctors found she had suffered a serious brain injury and she died on December 15.

Assistant coroner Simon Burge recorded a verdict of accidental death.

He said: I can’t find any suggestion or evidence that Irene was not cared for appropriately or that there’s any foul play or other relevant complicating factor that we need to take into account.”

The third Oaklands death was that of 94-year-old Joan Gould who died in September, 2014 after allegations, that she had been mistreated. These were never proven.

More than a year after her death, an inquest found Mrs Gould died of chronic heart failure.

The Winchester hearing heard how Mrs Gould suffered dementia, chronic heart swelling and hypertension.

She was taken to hospital in September, 2014 after a “complete vacancy of mind” lasting 40 minutes, the inquest heard.

She was later discharged to Oaklands, but the inquest heard she was removed days later by family who feared she was being mistreated. The details of their allegations were not disclosed to the hearing.

Relatives sent Mrs Gould back to Southampton General Hospital, where she died the next day on September 27.

In a report read to the hearing, Home Office pathologist Dr Basil Purdue found she died through heart failure.

“There were no features to suggest that Joan Gould had been subjected to neglect or ill treatment of any kind, and her body appeared well cared-for,” he said.

Senior central Hampshire coroner Grahame Short recorded a verdict of natural causes.

Oaklands declined to comment on the investigation.

But on its website it says: “Our staff are trained to NVQ Level 2, 3 and 4 and in accordance with the necessary regulations offer experienced care and support to our residents.

"Stimulation therapy is provided on a daily basis for those who wish to participate, including arts and crafts, one-on-one activity sessions, keep fit and board games.

“We offer only the best standards of care and comfort to our residents and we encourage friends and family to visit regularly and provide feedback to us about the service we provide.”